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_ ► <br /> �`�" , �-� <br /> :.:�t�.:�, -� <br /> -:������~ CITY of OROl\TO <br /> � -���; <br /> � <br /> .i <br /> Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> � h <br /> �� ' <br /> "�� _ � F. �'� ' On the North Shore of Lake Mirznetonka <br /> DATA_ PRIyACY ADVISORY <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> woul.d like to inform you that your request for a permit or license <br /> from the City of Orono or any of its departments may require you to <br /> furnish certain private or confidential information. <br /> You are notified that: <br /> 1. The information you furnish wi13 be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. <br /> 3. The information may be shared with other local , state or <br /> federal agencies to the extent necessary to process the permit or <br /> �icense. <br /> 4. If your requested permit or Iicense requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> data on yourself . <br /> 6, Your full name, and date of birth are required to process <br /> this application or permit. <br /> � � ��1 ����u � � �.� � l�� ✓ <br /> / _ , _,_ __ _. <br /> "'i�N� - ----- --- ------ <br /> _._._.._ --- -- __ _ <br /> First Middle Last <br /> �� �'� J (.�' �� 1 s � -�-� - - - - - <br /> Address <br /> . <br /> .- ��- -�s-------- -- -- - -- ��?�I -- --. -__ _--------S 5-�--�`' ---- --�----- - <br /> City State r <br /> c . � _ q �� �, � � <br /> Ut�� ._ c�� � -----_---___----- <br /> Phone <br /> I understand my rights as stated above. <br /> � �� <br /> 7iLLZ � � � � <br /> --...--- --� ---------- <br /> Si�nature <br /> BUILIIING&ZONING—473-735 i • ADMINISTRATION&FINANCE—d73-7358 • PUBLIC WORKS —473-7359 <br /> ASSESSI\G <br />